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United States Qualified Applicants

Location:
Haubstadt, IN, 47639
Posted:
February 09, 2024

Contact this candidate

Resume:

Your PD&S Agent, Inc.

**** ******** ****

Evansville, IN 47711

812-***-****

**-**-**** **:34:39AM CST

IntelliApp

Thank you for your interest in Your PD&S Agent, Inc.. To apply for a driving position, please complete our online application for employment. Incomplete information will delay the processing of your application or prevent it from being submitted. In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related disability, or any other protected group status.

Personal Information

Name Jimmy I Davis

Current Address 8005 Park Place Drive

Address 2 Apt. 29a

City, State/Province Zip/Postal Newburgh, IN 47630 Country United States

Residence 3 years or longer (If No,

previous addresses shown below)

No

Addresses Over last 3 years 1003 S Main St.

Fort Branch In 47648

July 1990

March 2022

SSN/SIN 1668

Date of Birth

Primary Phone 812-***-****

Cell Phone 812-***-****

Email ad3h5z@r.postjobfree.com

Yes, I agree to receive information

concerning future opportunities or

promotions from Your PD&S Agent, Inc. by

email or other commercial electronic

communications.

Yes

Would you like to receive communication

from Your PD&S Agent, Inc. via text

message?

By participating, you consent to receive

text messages sent by an automatic

telephone dialing system, which may

contain recruiting/advertising messages.

Consent to these terms is not a condition

Yes

1

of being hired, contracted, or leased. You

may opt out at any time by texting STOP to

unsubscribe. You also agree that Your

PD&S Agent, Inc.'s service provider

receives in real time and logs your text

messages with Your PD&S Agent, Inc..

Company Questions

GENERAL INFORMATION

What position are you applying for? Local Driver

Are you legally eligible for employment in

the United States?

Yes

Are you currently employed? Yes

What date did your last employment end?

Do you read, write, and speak English? Yes

Have you ever worked for this company

before?

No

Enter start and end dates, location,

position, and reason for leaving:

Do you have a current TWIC card? No

Expiration date:

Have you ever been known by any other

name?

No

Enter name:

How did you hear about us? Web

If "Driver Referral", please enter the

driver's name

If "Other", please explain

DRIVING EXPERIENCE

For each class of equipment, select years of experience. If no experience in a class, select "None".

Straight Truck None

Tractor and Semi-Trailer 10+ years

Tractor - Two Trailers None

Other

2

Licenses

License Number 870

Licensing Authority IN

Country US

License Class Class A

License Expiration Date 04-14-2026

DOT Medical Card Expiration Date 08-15-2023

Current License Yes

Commercial Driver License Yes

Endorsements

Tanker Endorsement Yes

HAZMAT Endorsement No

X Endorsement No

Doubles Triples Endorsement Yes

Other Endorsement No

Employment / Unemployment

J B Hunt Transport, Inc.

Company J B Hunt Transport, Inc.

Start Date 08-2023

End Date 12-2023

Address 4 J B Hunt Corporate Dr.

City, State/Province Zip/Postal Lowell, AR 72742

Country United States

Phone 479-***-****

Position Held Intermodal Driver

Reason for leaving? wanting home daily work

Were you terminated/discharged/laid off? No

Is this your current employer? Yes

May we contact this employer at this time? Yes

Did you operate a commercial motor

vehicle?

Yes

Were you subject to the Federal Motor

Carrier or Transport Canada Safety

Yes

3

Regulations while employed/contracted by

this employer/contractor?

Did you perform any safety sensitive

functions in this job, regulated by DOT,

and subject to drug and alcohol testing?

Yes

Areas Driven KY,IN,IL MO,AL, OH, WV, KS,IA .OH TN, GA, AL

Miles driven weekly 1500-2000

Pay Range (cents/mile) $ .61 per mile

Most common truck driven Conventional Tractor

Most common trailer Container

Trailer length 53 feet or more

Transforce

Company Transforce

Start Date 05-2023

End Date 09-2023

Address 11700 Commonwealth Drive, Suit

Address 2 Suite 800

City, State/Province Zip/Postal Louisville, KY 40299 Country United States

Phone 502-***-****

Position Held Driver

Reason for leaving? Still there

Were you terminated/discharged/laid off? No

Is this your current employer? No

May we contact this employer at this time? Yes

Did you operate a commercial motor

vehicle?

Yes

Were you subject to the Federal Motor

Carrier or Transport Canada Safety

Regulations while employed/contracted by

this employer/contractor?

Yes

Did you perform any safety sensitive

functions in this job, regulated by DOT,

and subject to drug and alcohol testing?

Yes

Areas Driven KY, IN, IL

Miles driven weekly 1500-2000

4

Pay Range (cents/mile) $26 an hour

Most common truck driven Day Cab Conventional

Most common trailer Van

Trailer length 53 feet or more

Bestway Express/KMA

Company Bestway Express/KMA

Start Date 08-2022

End Date 05-2023

Address 1665 S Old Us 41

City, State/Province Zip/Postal Vincennes, IN 47591 Country United States

Phone 812-***-****

Position Held Driver

Reason for leaving? Terminated

Were you terminated/discharged/laid off? Yes

Termination Explanation They provide labor for a company called Vascor at TMMI . I made some mistakes in

procedures over a series of months and

Vascor requested I be terminated

Is this your current employer? No

May we contact this employer at this time? Yes

Did you operate a commercial motor

vehicle?

Yes

Were you subject to the Federal Motor

Carrier or Transport Canada Safety

Regulations while employed/contracted by

this employer/contractor?

Yes

Did you perform any safety sensitive

functions in this job, regulated by DOT,

and subject to drug and alcohol testing?

Yes

Areas Driven IN

Miles driven weekly

Pay Range (cents/mile)

Most common truck driven Day Cab Conventional

Most common trailer Other

Trailer length 53 feet or more

O'bryan Barrel

5

Company O'bryan Barrel

Start Date 05-2019

End Date 07-2022

Address 5501 OLD BOONVILLE HWY

City, State/Province Zip/Postal Evansville, IN 47715 Country United States

Phone 812-***-****

Fax 812-***-****

Position Held Driver

Reason for leaving? Permanent lay off

Were you terminated/discharged/laid off? Yes

Termination Explanation Was injured on job when released for work was let go

Is this your current employer? No

May we contact this employer at this time? Yes

Did you operate a commercial motor

vehicle?

Yes

Were you subject to the Federal Motor

Carrier or Transport Canada Safety

Regulations while employed/contracted by

this employer/contractor?

Yes

Did you perform any safety sensitive

functions in this job, regulated by DOT,

and subject to drug and alcohol testing?

Yes

Areas Driven KY,IN,IL MO,AL, OH, WV, KS,IA .OH TN, GA, AL

Miles driven weekly

Pay Range (cents/mile)

Most common truck driven Day Cab Conventional

Most common trailer Van

Trailer length 53 feet or more

Unemployment

Start Date 04-2019

End Date 05-2019

Comment

KC Logistics, Inc

6

Company KC Logistics, Inc

Start Date 02-2014

End Date 03-2019

Address .239 County Road 100

City, State/Province Zip/Postal Princeton, IN 47670 Country United States

Phone 812-***-****

Fax 734-***-****

Position Held Driver

Reason for leaving? Quit

Were you terminated/discharged/laid off? No

Is this your current employer? No

May we contact this employer at this time? Yes

Did you operate a commercial motor

vehicle?

Yes

Were you subject to the Federal Motor

Carrier or Transport Canada Safety

Regulations while employed/contracted by

this employer/contractor?

Yes

Did you perform any safety sensitive

functions in this job, regulated by DOT,

and subject to drug and alcohol testing?

Yes

Areas Driven IN

Miles driven weekly

Pay Range (cents/mile)

Most common truck driven Day Cab Conventional

Most common trailer Van

Trailer length 53 feet or more

Walt's Drive Away

Company Walt's Drive Away

Start Date 10-2000

End Date 02-2014

Address 4600 Hitch & Peters Road

City, State/Province Zip/Postal Evansville, IN 47711 Country United States

Phone 812-***-****

7

Position Held Driver

Reason for leaving? Quit

Were you terminated/discharged/laid off? No

Is this your current employer? No

May we contact this employer at this time? Yes

Did you operate a commercial motor

vehicle?

Yes

Were you subject to the Federal Motor

Carrier or Transport Canada Safety

Regulations while employed/contracted by

this employer/contractor?

Yes

Did you perform any safety sensitive

functions in this job, regulated by DOT,

and subject to drug and alcohol testing?

Yes

Areas Driven KY, IN, IL,MO

Miles driven weekly

Pay Range (cents/mile)

Most common truck driven Conventional Tractor

Most common trailer Container

Trailer length 53 feet or more

U.S. Military

Branch of Service Navy

Start Date 08-1973

End Date 08-1977

Can you obtain your DD214? No

Rank at discharge Third class petty officer

FMCSR

Under FMCSR 391.15, are you currently

disqualified from driving a commercial

motor vehicle? [49 CFR 391.15]

No

Has your license, permit or privilege to

drive ever been suspended or revoked for

any reason? [49 CFR 391.21(b)(9)]

No

Have you ever been denied a license,

permit, or privilege to operate a motor

No

8

vehicle?[49 CFR 391.21(b)(9)]

Within the past two years, have you tested

positive, or refused to test, on a

pre-employment drug or alcohol test by an

employer to whom you applied, but did not

obtain, safety-sensitive transportation work

covered by DOT agency drug and alcohol

testing rules? [49 CFR 40.25(j)]

No

In the past three(3) years, have you ever

been convicted of any of the following

offenses: [49 CFR 391.15]:

Driving a commercial motor vehicle

with a blood alcohol concentration

("BAC") of .04 percent or more

·

Driving under the influence of

alcohol, as prescribed by state law

·

Refusal to undergo drug and

alcohol testing as required by any

jurisdiction for the enforcement of

Federal Motor Carrier Safety Act

regulations

·

Driving a commercial motor vehicle

under the influence of any 21

C.F.R. 1308.11 Schedule I

identified controlled substance, an

amphetamine, a narcotic drug, a

formulation of an amphetamine, or

a derivative of a narcotic drug

·

Transportation, possession, or

unlawful use of a 21 C.F.R.

1308.11 Schedule I identified

controlled substance,

amphetamines, narcotic drugs,

formulations of an amphetamine, or

derivatives of narcotic drugs while

you were on duty driving for a

motor carrier

·

Leaving the scene of an accident

while operating a commercial motor

vehicle

·

Or any other felony involving the

use of a commercial motor vehicle

·

No

Vehicle Accident Record

Were you involved in any accidents/incidents with any vehicle in the last 5 years (even if not at fault)?

Type of Accident / Incident Non-Injury

Date of Accident / Incident 02-2021

9

Hazmat Accident / Incident No

Was the vehicle towed away? Yes

City Near Mill Shoals

State/Province IL

Were you in a commercial vehicle? Yes

If yes, was this a Department of

Transportation recordable accident?

Yes

Were you at fault? No

Were you ticketed? No

Description Was driving west on I-64 . The road was icy box van tried to pass lost control hit my

truck and caused us both to go into right

shoulder.

Traffic Convictions \ Violations

Have you had any moving violations or traffic convictions in the past 3 years? No Violations

Criminal Record

Have you ever been convicted of a crime? Yes

Comment around 1978 shoplifting on jailtime just

paid a fine

Do you have any deferred prosecutions? No

Do you have criminal charges pending? No

Have you ever pled "guilty" to, been

convicted of, or pled "no contest" to a

felony?

No

If you have any felony convictions, do you

currently hold a minister's permit to enter

or exit Canada?

No

Have you, within the last five years, pled

"guilty" to, been convicted of, had

prosecution deferred in connection with, or

pled "no contest" to a misdemeanor?

No

10

Signature

Full Name Jimmy I Davis

IP Address 149.75.22.110

Signature Date/Time 12-07-2023 10:34 AM

By signing my application below, I agree to use an electronic signature to demonstrate my consent. An electronic signature is as legally binding as an ink signature. This certifies that this application was completed by me, and that all entries on it and information in it are true and complete to the best of my knowledge.

Signed Date: 12-07-2023 10:34 AM

Signed:

Federal FCRA Summary of Rights Acknowledgment

By checking this box, I (a) acknowledge

that I have read and understand the

federal FCRA Summary of Rights and

have been given the opportunity to

copy/print the Summary of Rights and (b)

agree to use an electronic signature to

demonstrate my consent. An electronic

signature is as legally binding as an ink

signature.

Yes

PSP Disclosure and Authorization

By checking the box, I (a) acknowledge

that I have read and understand the PSP

Disclosure and Authorization and also

have been given the opportunity to

copy/print it, and (b) agree to use an

electronic signature to demonstrate my

consent. An electronic signature is as

legally binding as an ink signature.

Yes

FCRA Disclosure

By checking the box, I (a) acknowledge

that I have read and understand the above

and also have been given the opportunity

to copy/print it, and (b) agree to use an

Yes

11

electronic signature to demonstrate my

consent. An electronic signature is as

legally binding as an ink signature.

FCRA Authorization

By checking the box, I (a) acknowledge

that I have read and understand the above

and also have been given the opportunity

to copy/print it, and (b) agree to use an

electronic signature to demonstrate my

consent. An electronic signature is as

legally binding as an ink signature.

Yes

Employment Verification Acknowledgment and Release (DOT Drug and Alcohol) By checking the box, I (a) acknowledge

that I have read and understand the above

and also have been given the opportunity

to copy/print it, and (b) agree to use an

electronic signature to demonstrate my

consent. An electronic signature is as

legally binding as an ink signature.

Yes

Clearinghouse Release

By checking the box, I (a) acknowledge

that I have read and understand the above

and also have been given the opportunity

to copy/print it, and (b) agree to use an

electronic signature to demonstrate my

consent. An electronic signature is as

legally binding as an ink signature.

Yes

1681m

By checking this box, I represent that I

understand and agree to the above

document.

Yes

INVESTIGATIVE CONSUMER REPORT DISCLOSURE

By checking this box, I represent that I

understand and agree to the above

document.

Yes

12

User Requested Copy

User requested a copy to be sent to this

email address ad3h5z@r.postjobfree.com.

Yes

13

DISCLOSURE FOR CONSUMER REPORTS

In connection with your employment or owner-operator (independent contractor) application, Your PD&S Agent, Inc. may order one or more consumer report(s) (commonly known as "background reports" or "background checks") about you from one or more consumer reporting agencies. If you are hired or engaged as an owner-operator (independent contractor), additional consumer reports may be obtained in connection with and throughout your employment for employment purposes or for the legitimate business purpose of evaluating you as an owner-operator.

To the extent allowed by law, the consumer reports may include information concerning your character, general reputation, personal characteristics, mode of living, drug and alcohol test results, motor vehicle records, driving records, criminal history, public court records, employment history (including names and dates of previous employers, reason for termination of employment, work experience, and accidents), social security number validation, education, licensure, or verification of other information supplied by you. Such reports may be obtained from private and public record sources, including sanctions databases, CDLIS (including but not limited to CDLIS Central Site, CDLIS Master Pointer Record data and your driver record from the jurisdiction identified in the CDLIS data, in accordance with applicable state law and the Driver Privacy Protection Act), former employers, public court records, and federal, state, and other government agencies that maintain such records. Printed Name:

Jimmy I Davis

Social Security #:

1668

Signed Date: 12-07-2023

Jimmy I Davis

8005 Park Place Drive

Apt. 29a

Newburgh, IN 47630

812-***-****

Gender:

14

AUTHORIZATION FOR CONSUMER REPORTS

I authorize Your PD&S Agent, Inc. to obtain one or more consumer report(s) or investigative consumer report(s) about me. If hired or engaged as an owner-operator (independent contractor), I understand this authorization shall remain on file and shall serve as ongoing authorization for additional consumer reports or investigative consumer reports to be obtained from any consumer reporting agency at any time during my employment or contract period without asking me for authorization again. Printed Name:

Jimmy I Davis

Social Security #:

1668

Signed Date: 12-07-2023

Jimmy I Davis

8005 Park Place Drive

Apt. 29a

Newburgh, IN 47630

812-***-****

Gender:

15

IMPORTANT DISCLOSURE

REGARDING BACKGROUND REPORTS FROM THE PSP Online Service In connection with your application for employment with Your PD&S Agent, Inc. ("Prospective Employer"), Prospective Employer, its employees, agents or contractors may obtain one or more reports regarding your driving, and safety inspection history from the Federal Motor Carrier Safety Administration (FMCSA).

When the application for employment is submitted in person, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer will provide you with a copy of the report upon which its decision was based and a written summary of your rights under the Fair Credit Reporting Act before taking any final adverse action. If any final adverse action is taken against you based upon your driving history or safety report, the Prospective Employer will notify you that the action has been taken and that the action was based in part or in whole on this report. When the application for employment is submitted by mail, telephone, computer, or other similar means, if the Prospective Employer uses any information it obtains from FMCSA in a decision to not hire you or to make any other adverse employment decision regarding you, the Prospective Employer must provide you within three business days of taking adverse action oral, written or electronic notification: that adverse action has been taken based in whole or in part on information obtained from FMCSA; the name, address, and the toll free telephone number of FMCSA; that the FMCSA did not make the decision to take the adverse action and is unable to provide you the specific reasons why the adverse action was taken; and that you may, upon providing proper identification, request a free copy of the report and may dispute with the FMCSA the accuracy or completeness of any information or report. If you request a copy of a driver record from the Prospective Employer who procured the report, then, within 3 business days of receiving your request, together with proper identification, the Prospective Employer must send or provide to you a copy of your report and a summary of your rights under the Fair Credit Reporting Act. Neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. You may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If you challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. Your request will be forwarded by the DataQs system to the appropriate State for adjudication.

Any crash or inspection in which you were involved will display on your PSP report. Since the PSP report does not report, or assign, or imply fault, it will include all Commercial Motor Vehicle (CMV) crashes where you were a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, all inspections, with or without violations, appear on the PSP report. State citations associated with Federal Motor Carrier Safety Regulations (FMCSR) violations that have been adjudicated by a court of law will also appear, and remain, on a PSP report. The Prospective Employer cannot obtain background reports from FMCSA without your authorization. AUTHORIZATION

If you agree that the Prospective Employer may obtain such background reports, please read the following and sign below: I authorize Your PD&S Agent, Inc. ("Prospective Employer") to access the FMCSA Pre-Employment Screening Program (PSP) system to seek information regarding my commercial driving safety record and information regarding my safety inspection history. I understand that I am authorizing the release of safety performance information including crash data from the previous five (5) years and inspection history from the previous three (3) years. I understand and acknowledge that this release of information may assist the Prospective Employer to make a determination regarding my suitability as an employee.

I further understand that neither the Prospective Employer nor the FMCSA contractor supplying the crash and safety information has the capability to correct any safety data that appears to be incorrect. I understand I may challenge the accuracy of the data by submitting a request to https://dataqs.fmcsa.dot.gov. If I challenge crash or inspection information reported by a State, FMCSA cannot change or correct this data. I understand my request will be forwarded by the DataQs system to the appropriate State for adjudication. I understand that any crash or inspection in which I was involved will display on my PSP report. Since the PSP report does not report, or assign, or imply fault, I acknowledge it will include all CMV crashes where I was a driver or co-driver and where those crashes were reported to FMCSA, regardless of fault. Similarly, I understand all inspections, with or without violations, will appear on my PSP report, and State citations associated with FMCSR violations that have been adjudicated by a court of law will also appear, and remain, on my PSP report. I have read the above Disclosure Regarding Background Reports provided to me by Prospective Employer and I understand that if I sign this Disclosure and Authorization, Prospective Employer may obtain a report of my crash and inspection history. I hereby authorize Prospective Employer and its employees, authorized agents, and/or affiliates to obtain the information authorized above. Printed Name:

Jimmy I Davis

Signed Date: 12-07-2023

16

Consent for Limited Queries of the Federal Motor Carrier Safety Administration (FMCSA) Drug and Alcohol Clearinghouse

I hereby provide consent to Your PD&S Agent, Inc. to conduct a limited query of the FMCSA Commercial Driver's License Drug and Alcohol Clearinghouse to determine whether drug or alcohol violation information about me exists in the Clearinghouse. I understand this consent shall remain on file and shall serve as ongoing consent for Your PD&S Agent, Inc. to conduct multiple limited queries of the Clearinghouse at any time during my employment or contract period without asking me for additional consent. I understand that if I refuse to provide consent for Your PD&S Agent, Inc. to conduct a limited query of the Clearinghouse, Your PD&S Agent, Inc. is required to prohibit me from performing safety-sensitive functions, including operating a commercial motor vehicle. I understand that if the limited query conducted by Your PD&S Agent, Inc. indicates that drug or alcohol information exists about me in the Clearinghouse, the FMCSA will not disclose that information to Your PD&S Agent, Inc. unless I give additional specific consent within the Clearinghouse. However, I understand that Your PD&S Agent, Inc. will be required to conduct a full query of the Clearinghouse within 24 hours after a limited query indicates that drug or alcohol information exists and that if I do not grant consent within the Clearinghouse for that full query I will be removed from performing safety-sensitive functions, including operating a commercial motor vehicle.

12-07-2023

Jimmy I Davis Date

17

Request/Consent for Information from Previous Employer(s)/Carrier(s) For Alcohol and Controlled Substances Testing Records

And changes in Parts 390 and 391 of the FMCSA

X 12-07-2023

Date

X 1668

Social Security Number

Jimmy I Davis

8005 Park Place Drive

Apt. 29a

Newburgh, IN 47630

812-***-****

Gender:

X Jimmy I Davis

Print Name (First, MI, Last)

X

Signature

I, the above mentioned signer, hereby authorize J B Hunt Transport, Inc. To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to Your PD&S Agent, Inc.

DISCLOSURE AND AUTHORIZATION UNDER 49 C.F.R. PART 391.23 INCLUDING DOT DRUG AND ALCOHOL INFORMATION

For purposes of an investigation in accordance with 49 C.F.R. Part 391.23, I authorize my previous employers, contractors (if owner-operator), and trucking schools, as applicable, to release and forward to Your PD&S Agent, Inc. ("Company") the following information for the past three (3) years:

1. DOT alcohol and controlled substance information in accordance with Parts 382 and 40 of the Federal Motor Carrier Safety Regulations (49 CFR Part 382 and 49 CFR Part 40, Section 40.25) limited to the following DOT regulated testing items, including pre-employment testing results: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested;

(iv) other violations of DOT agency drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) documentation, if any, of completion of the return-to-duty process following a rule violation. 2. Safety performance history information in accordance with 49 CFR Part 391.23, which includes: employment dates, work history

(which may include position held, reason for leaving, any termination information, whether subject to the Federal Motor Carrier Safety Administration regulations, equipment experience, area driven, and other information as applicable) and accident information

(including accident date, nature of accident, whether it was preventable, whether there were injuries, fatalities, or hazardous materials involved, and copies of any accident report).

Pursuant to Section 391.23(i) of the Federal Motor Carrier Safety Regulations, you have the following rights with regard to the information released:

1. You have the right to make a written request at any time to review the information provided by previous employers, contractors (if owner-operator), or trucking schools, as applicable. 2. You have the right to have errors in the information corrected by the previous employer, contractor (if owner-operator), or trucking school, as applicable and for that employer, contractor (if owner-operator), or trucking school to re-send the corrected information. 3. You have the right to have a rebuttal statement attached to the alleged erroneous information if the previous employer, contractor (if owner-operator), or trucking school and you cannot agree on the accuracy of the information. 18

Request/Consent for Information from Previous Employer(s)/Carrier(s) For Alcohol and Controlled Substances Testing Records

And changes in Parts 390 and 391 of the FMCSA

X 12-07-2023

Date

X 1668

Social Security Number

Jimmy I Davis

8005 Park Place Drive

Apt. 29a

Newburgh, IN 47630

812-***-****

Gender:

X Jimmy I Davis

Print Name (First, MI, Last)

X

Signature

I, the above mentioned signer, hereby authorize Transforce To release and forward in accordance with the following regulation, all known information pertaining to my alcohol and controlled substances testing/training records to Your PD&S Agent, Inc.

DISCLOSURE AND AUTHORIZATION UNDER 49 C.F.R. PART 391.23 INCLUDING DOT DRUG AND ALCOHOL INFORMATION

For purposes of an investigation in accordance with 49 C.F.R. Part 391.23, I authorize my previous employers, contractors (if owner-operator), and trucking schools, as applicable, to release and forward to Your PD&S Agent, Inc. ("Company") the following information for the past three (3) years:

1. DOT alcohol and controlled substance information in accordance with Parts 382 and 40 of the Federal Motor Carrier Safety Regulations (49 CFR Part 382 and 49 CFR Part 40, Section 40.25) limited to the following DOT regulated testing items, including pre-employment testing results: (i) alcohol tests with a result of 0.04 or higher; (ii) verified positive drug tests; (iii) refusals to be tested;

(iv) other violations of DOT agency drug and alcohol testing regulations; (v) information obtained from previous employers of a drug and alcohol rule violation; and (vi) documentation, if any, of completion of the return-to-duty process following a rule violation. 2. Safety performance history information in accordance with 49 CFR Part 391.23, which includes: employment dates, work history

(which may include position held, reason for leaving, any termination information, whether subject to the Federal Motor Carrier Safety Administration regulations, equipment experience, area driven, and other



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